Every angry depressed person who kills themselves or others, the internet is full of rants condemning giving SSRI antidepressants to people, especially teens.

In the days before anti depressants, we didn’t see this, did we?

No, but on the other hand, thirty years ago there was a lot less social pathology and “recreational drugs”, a lot less graphic violence to desensitize people against committing violence, and no “24/7” programs that sent messages that suggest the idea of suicide and homicide to those easily influenced. The link between publicity and “copy cat” crimes including suicide is well documented.

So this week, there’s a lot of stuff in the news saying that double blind studies don’t show a difference in treating with anti depressants and no medicine.

Good news for those who like to demonize drug companies (it IS an election year).

These studies were done on mild to moderate depression, and docs have known for years that mild depression usually responds well to TLC (tender loving care) and tincture of time.

The real problem with these studies is that they didn’t compare “no treatment” versus pills. When they did the study, the patients got an in depth analysis by docs and a lot of follow up visits. Essentially both groups were treated with intensive TLC and Tincture of time and did well…but one group got pills with the TLC and the other one didn’t.

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Reality check, please.

One reason the pills are popular is that docs in HMO’s or busy practices don’t have all that time to talk to patients, so the temptation is to give out the pills.

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So instead of the olden days when you saw Dr. X, who has been taking care of you since you were a kid, to talk to him/her about your problem, you now see the doc on call who doesn’t know you from beans, who talks to you ten minutes and starts Prozac or whatever.

Oh, he has all that “medical information” on your chart (thanks to electronic medical records) but he doesn’t know this is the anniversary of your mom’s death, or that you had an abortion but were afraid to tell your mom, or that your husband has a bimbo on the side…all that little stuff that old Dr. X would know. That stuff isn’t on your chart….indeed, there’s a lot of stuff that doesn’t go on charts…your cousin Millie works in the billing office, and she’s been known to gossip….

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So the doc sees you, does a physical and some lab tests, gives you a pill, says he’ll see you in ten days.

Luckily, the HMO will allow doctors one or two follow up visits to check if the pill is making you manic/angry/suicidal and to review the lab tests (since a dozen diseases, from Diabetes to thyroid problems to cancer to low grade hepatitis can cause depression).

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And a lot of time the real problems get discussed at that second or third visit, and you get better. In the meanwhile, the medicine does make you feel a little more normal, and you slowly recover.

The dirty little secret is that if you tell a person: you’re depressed but I’m not going to give you pills because they don’t work, just an appointment with a therapist two or three weeks from now, well, a lot of those people never follow up with anyone.

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It’s probably cultural, but if you don’t do a physical, people think you aren’t being a doctor, and if you aren’t giving pills, people think they aren’t getting treated (even though a significant number of them never fill the prescription).

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But I’m not convinced pills don’t help.

First of all, there are few medicines that work much “better” than “placebo”…but, as I mentioned above, this is often because the therapy we give with the medicine or placebo makes the big difference, whether you are talking about pain pills, anti depressants, or people with wounds or infections.

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Second:If given correctly, the newer anti depressant pills merely make you feel more nomal, and you can then cope with your problems (often with a little help from your counseler, your pastor, or your best friend).

Since “feeling normal” is a subtle thing, it may be hard to measure.

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Third: the only “Hard” data end point of depression that can easily be measured is suicide. And not only does the data show that the drugs do help in severe depression, but that since we started using the newer anti depressants (the SSRI drugs) fewer people have committed suicide:

Jens Ludwig, of the University of Chicago, argues that countries that took to the new drugs saw a relative decline in suicides. After controlling for many variables, his NBER team reaches the cheerful conclusion that an increase in sales of one pill per person per year (about a 12% increase over the level in 2000) leads to a decline in suicide mortality of about 5%.

All I know is that my mildly depressed menopausal women come in saying that when they stop the pill, their husbands are the first to notice and ask them if they forgot to take their pill. (Often they don’t need the SSRI for long: often only a couple months until their hormones settled down).

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Two notes on medicine: One, a lot of time for severe depression you might need “combination therapy”, or a lot higher dosage than can be given by your Family doctor. So if one pill doesn’t work, or makes you feel wrong, try another. Often I find these patients have Post traumatic stress syndrome, or suffer from Bipolar illness with depression, and need more expert help than I can give them.

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Two: Depression has a “biochemical” component. So people with chronic illnesses, from Diabetes to cancer, often suffer from low grade depression. They feel tired all the time, “the blahs”, but can’t figure out why. Often anti depressants help in this too.

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Finally, there are still some strong minded people who insist that “it’s all in the head” and if you “buck up” things will get better.

Well, things do get better in time, but those who scoff at suffering have never been there. To those scoffers, I often remind them:

O the mind, mind has mountains; cliffs of fall Frightful, sheer, no-man-fathomed. Hold them cheap May who ne’er hung there.

3 users commented in " The truth about depression medicine "

In fact we did see angry kids shooting themselves and others long before antidepressants, and particularly SSRIs became readily available.

For example, the first school shooting occurred in 1966 (University of Texas at Austin), and they have occurred at 1-2 year intervals since. The first tricyclic antidepressants date to about 1968, and SSRIs were first released in the U.S. in 1989.

As for the recent Kirsch study, while the authors claim that antidepressants aren’t effective in moderate to severe depression, the studies they used for their meta-analysis were almost all of very severely depressed patients. On a small number of subjects in one small study were moderately depressed. So the conclusion Kirsh et al. reached is not supported by any of the data in their study. Nor is this the only flaw.

Sam said,

in February 29th, 2008 at 6:13 pm

I hate to say it, but this is another typical Doctor Rant about the wonders of the anti-depressant drugs missing the whole entire sad point. This is hardly “the “truth” about depression medicine” – the very title of the piece betrays the prejudice of the writer. If one were to read a detailed careful study of this controversial issue in the recent British Medical Journal, you would see that the so-called “truth” is hardly that clear.
Go to the website called Effexor Petition and read thousands of patients talking about the effects of one particular anti-depressant on their lives and you will get some notion of the risk of these drugs for some people. The notion that these drugs have reduced suicide rates and that the black box warnings have caused more suicide is simply NOT TRUE. If you read the warnings, they are nothing more or less than common sense.. advising doctors to use caution, to use some reasonable practices in treating patients rather than just prescribing pills the way the doctor suggests. These medicines have effect on the brain.. They are not candy, not aspirin, not some harmless medicine.. they carry serious risk and must be managed seriously.. That is really the trouble. They have been prescribed so easily without regard for risk. That is THE TRUTH.
We need psychiatrists who spend the time to read up about the medicines and properly inform patients and families about warning signs. Most simply were not doing that. There is loads of evidence. Could they be helpful..? Yes, in some cases.. but it is not as simple as the doctor puts it here.
And some of what she writes here is simply NOT THE TRUTH…
Not exactly lies, but distortions of the real scientific facts and the recent research on this. Some of these drugs do increase risk of suicidal thoughts and ideation. There are anecdotal cases.. even a case of a normal subject in a study without a history of suicidal tendencies who actually killed herself in the laboratory of the manufacturer. The one case does not make a study, but the mere fact that these drugs do cause increased suicidal thoughts, means they have to be managed very very very carefully.. That is the truth…
Sam

Many times pain is th cause of depression and it is the use as SSRIs that instigate and participates the increase in chronic pain making life unable to these that are deprived pain relive. The same receptors in the brain that our bodies receive our own bodies endorphins ( our bodies opiates)causing a increase of agitations and some pain receptions.

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